British Journal of Radiology (2007) 80, e128-e130
© 2007 British Institute of Radiology
doi: 10.1259/bjr/60325018
Granulocytic sarcoma manifested as a parametrial mass mimicking a haemorrhagic abscess: a case report with CT and MR findings
S W Ko, MD
Y K Kim, MD
G Y Jin, MD
S Y Lee, MD
and
C S Kim, MD
Department of Diagnostic Radiology, Chonbuk University Medical School, 634-18 Geumam 2 dong, Dukjin gu, Jeonju City, Chonbuk, South Korea, 561-712
Correspondence: Young Kon Kim, MD, Department of Diagnostic Radiology, Chonbuk University Medical School, 634-18 Geumam 2 dong, Dukjin gu, Jeonju city, Chonbuk, South Korea, 561-712. E-mail: jmyr{at}dreamwiz.com
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Abstract
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Granulocytic sarcoma is a neoplasm arising from myeloid precursor cells and frequently accompanies leukaemia and myeloproliferative disorders. Granulocytic sarcoma can arise anywhere, and it frequently involves bones, perineural tissues and lymph nodes. However, granulocytic sarcoma in the female genital organs is uncommon, and it is extremely rare that it presents as an adnexal or parametrial mass. We report here the CT and MR findings in a case of granulocytic sarcoma that manifested as a uterine cervical and parametrial mass mimicking a haemorrhagic abscess in a 50-year-old woman with chronic myelogenous leukaemia.
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Introduction
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Focal lesions developing in the course of myelogenous leukaemia may consist of infection, haemorrhage, neoplasm or granulocytic sarcoma, and early diagnosis of each complication is very important [1–3]. Granulocytic sarcoma is a rare extramedullary tumour composed of immature myeloid precursor cells [1–4]. In females, granulocytic sarcoma more commonly occurs in the ovary, and several cases have been reported arising from the other genital organs [4–8]. Granulocytic sarcoma that presents as an adnexal or parametrial mass is extremely rare, and very few articles have reported the radiological findings of this disease entity. We report a case of granulocytic sarcoma arising from the uterine cervical and parametrial regions mimicking a haemorrhagic abscess in a 50-year-old woman with chronic myelogenous leukaemia.
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Case report
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A 50-year-old woman was admitted to hospital with a 1 day history of lower abdominal pain and right flank pain. She was diagnosed as having chronic myelogenous leukaemia (CML) about 9 months ago, and she has been receiving anti-leukaemic treatment. She had been stable regarding CML before admission. Her physical examination revealed a hard, tender mass in the pelvic cavity. The laboratory findings revealed the presence of myeloblasts in the peripheral blood smear and the bone marrow specimen, which suggested a diagnosis of the blastic phase of CML. Her serum CA19-9 and CA125 levels were normal. There was no micro-organism isolated from her cerebrospinal fluid (CSF), blood and urine.
Initial abdominopelvic CT (Somatom Sensation 16; Siemens, Erlangen, Germany) demonstrated a poorly defined, heterogeneously strongly enhancing mass in the uterine cervix and the right parametrium (Figure 1a
). The mass had infiltrated into the right posterior urinary bladder, which resulted in acute moderate hydronephrosis in the ipsilateral kidney. Normal ovaries are seen as nodular enhancing structures with small follicles. On the MRI performed on a 1.5 T (Magnetom Symphony; Siemens, Erlangen, Germany), the pelvic mass was revealed as a large infiltrative mass in the uterine cervix and the right parametrium, and the mass also contained internal haemorrhagic foci. The mass showed heterogeneous, mixed signal intensities on both T1 weighted and T2 weighted images (Figure 1b,c). Gadolinium (Gd)-diethylenetriamine pentaacetic acid (DTPA) enhanced MRI revealed an approximately 6 x 6 cm strongly enhancing, infiltrative mass with central non-enhancing portions that was mainly in the right parametrium, and it mimicked an abscess (Figure 1d). The mass had infiltrated the right parametrium and the right posterior urinary bladder, and it extended along the ipsilateral visceral pelvic fascia.
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Figure 1. Granulocytic sarcoma in a 50-year-old woman mimicking a parametrial haemorrhagic abscess. (a) Contrast-enhanced CT shows a densely enhanced, bulky mass in the right parametrium (white arrow). Focal obliteration of the fat layer between the right posterior urinary bladder and the uterus is demonstrated (black arrow), and there is no visualization of the opacified right distal ureter. Axial T1 weighted (b) and T2 weighted (c) images show a large, infiltrating mass in the uterine cervix and right parametrium. Globular enlargement of the uterine cervix and the poorly defined, haemorrhagic portions in the right parametrium (short arrow in b) are demonstrated. Thickening of the right side of the posterior urinary bladder and obliteration of the retrovesical fat are also noted (long arrow in b and arrows in c). (d) Axial contrast-enhanced T1 weighted image with a fat suppression technique demonstrates a densely enhancing uterine cervix and a poorly marginated, thick, irregular peripheral enhancing mass in the right parametrium that contains central non-enhancing portions mimicking an abscess (long arrows). The mass is infiltrated into the right side of the posterior urinary bladder (short arrow), the retrovesical fat and the visceral pelvic fascia. (e) Photomicrograph (haematoxylin/eosin stain, original magnification x 400) shows diffuse infiltrate of leukaemic blasts. (f) On the follow-up contrast-enhanced CT after anti-leukaemic chemotherapy, the parametrial mass shows a markedly decreased size and enhancement (long arrow). Note the normal configuration of the right side of the posterior urinary bladder and the preserved retrovesical fat (short arrow).
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The laparoscopic biopsy of the right parametrial mass and a punch biopsy of the endocervix were performed immediately after the MR examination. Histopathologically, the specimen was characterized by a diffuse infiltrate of leukaemic blasts, and this was consistent with granulocytic sarcoma (Figure 1e
). The patient received anti-leukaemic chemotherapy for 2 weeks and underwent follow-up abdominopelvic CT. On the follow-up CT, the mass showed a marked decrease in size and somewhat decreased contrast enhancement. Infiltration into the urinary bladder, retrovesical fat and visceral pelvic fascia was also improved (Figure 1f), and the right renal hydronephrosis had disappeared.
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Discussion
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Granulocytic sarcoma (GS) is also termed chloroma, myelosarcoma or extramedullary myeloid cell tumour, and it is a localized extramedullary neoplasm composed of immature myeloid precursor cells. The term granulocytic sarcoma was first used by Rappaport in 1966 [1–3]. GS is most commonly encountered in patients with acute and chronic myeloid leukaemia, and it may be seen in those patients with myelodysplastic syndrome and other myeloproliferative disorders [1, 4]. GS can be found in almost any organ, but it is reported to be found especially in bones, skin, nervous tissues and soft tissues [1–3], and it may arise from nests of haematopoietic cells in the genitourinary tract [9]. GS found in the female genital tract is rare, and very few articles have described the radiological manifestations of this tumour when it involves the ovary, uterus and uterine cervix [3–8].
There are a few characteristic radiological features of GS. Pui et al [2] have reported that GS tumours of the head and spine in children were isointense to brain, bone marrow and muscle tissue on both T1 weighted and T2 weighted images, and the tumour was enhanced homogeneously. Ooi et al [1] have reported that the signs strongly suggestive of GS in adults are multiple, enhancing, solid masses occurring at different sites in a patient having either leukaemia or one of the myeloproliferative disorders. Ooi et al have also found GS that was akin to an abscess in the various organs, except they did not find it in the genitourinary tract, and the authors suggested that mild hyperintensity on T2 weighted images due to the lack of a cystic centre can be a useful finding to differentiate this tumour from an abscess.
In this case, the signal intensities of the mass on T1 and T2 weighted images were heterogeneous and mixed with low and high signal intensities, and the mass contained internal haemorrhagic foci of high signal intensity. On the Gd-enhanced MR images, the mass showed thick, irregular peripheral enhancement that infiltrated into the adjacent urinary bladder and visceral pelvic fascia, and it contained central non-enhancing portions. The Gd-enhanced MR findings of the mass were quite similar to that of an abscess with haemorrhage. After analysing the MR findings in this case, we have concluded that there is not such a high signal intensity on the T2 weighted images as is usually seen for abscesses, and this can be an important point in differentiating this lesion from an abscess, as mentioned above.
We should discriminate GS from an abscess, haematoma, lymphoma and the other malignant lesions that can occur in patients with leukaemia in order to initiate prompt and appropriate therapy and to avoid any unnecessary operation. In summary, we report here the CT and MR findings of a granulocytic sarcoma arising from the female genital organs that mimicked an abscess with haemorrhage in a patient with chronic myelogenous leukaemia. We believe that MRI can be a helpful diagnostic method of making a differential diagnosis of granulocytic sarcoma in a patient with leukaemia, and this can be done by analysing the signal intensity and the enhancement pattern.
This work was supported by a Chonbuk University grant in 2004.
Received for publication April 20, 2005.
Revision received October 3, 2005.
Accepted for publication October 26, 2005.
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References
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Abstract
Introduction
